• Request a demo of the AI-driven technology that's changing healthcare

    Ready to see how we're starting the healthcare revolution? Complete the form below and a member of our team will be in touch with you soon about a demo.

  • This field is for validation purposes and should be left unchanged.
Blog   |   5.20.21

Avoid Audit Risk by Looking Both Ways

During the RISE National Conference this Spring, the Office of the Inspector General (OIG) announced that in one of their Risk Adjustment Audits they found $14.5 million in overpayments due to submitted diagnosis codes that were unsupported. Interestingly enough, this is not an isolated case. In fact, the OIG also reported in another recent finding that a payer organization allegedly overcharged the federal government by more than $150 million for submitting documentation that inaccurately showed some of its MA members sicker than they actually were.

How could this have happened? 

So what is the root cause of all these errors? There are a myriad of causes – including but not limited to encounter data lacking essential information, missing NPI requirements, fraudulent or insufficient codes being submitted along with continuous guideline updates that may cause confusion to the coders. These types of issues are often only half the problem – most organizations do not have the time and resources to do regular audits of their coding activities – putting their organization at financial and audit risk. In a  recent coder survey 50% of health plan coders claimed their organization completed QA on less than 10% of coded patient charts.1 To achieve the most accurate risk scores and reduce audit risk, organizations need to look both ways by utilizing solutions that add and remove HCC codes appropriately. Data shows:

  • In 2017, $2.7 billion in MA Risk Adjustment payments were not linked to any services
  • Medicare saw that 19% of submissions lacked sufficient documentation 

The pace and frequency of audits and legal action are becoming seemingly more regular. Organizations need to make certain that they have a well documented and effective compliance process to help ensure that their retrospective reviews do not put their organization at risk.

There is also a need to address and relieve the mounting pressure regulatory bodies, such as OIG, DOJ, CMS and others, are placing on overpayments and fraudulent claims coding. A part of doing so, is to limit the possibility for organizations, or these organizations coding vendors, to overcode for services by auditing the findings for correct and complete capture.    

How can your organization avoid these problems? 

It is imperative that your organization utilize a trusted solution that supports internal and RADV audits of your risk or government programs in a complete and accurate manner. Manually looking both ways is time consuming, costly, and unscalable and many organizations aren’t performing the level of coding audits they should to protect their programs. 

With Apixio’s HCC Complete, AI-powered coding & audit solution, your team can take control of your risk adjustment for Medicare Advantage, ACA, and APM programs. Based on Apixio’s experience of more than 21M patient lives, our Best in KLAS software solution saw a range from 3 to as much as 18% of MA plan claims that lacked sufficient supporting evidence. Our HCC Complete solution looks both ways by reviewing charts for net new HCC codes and removing HCC codes that are unsupported, ensuring accurate and compliant coding. With the use of our AI product, payers and providers can also see increased productivity, streamlined workflows, QA up to 100% of coding opportunities and implement multiple levels of QA.

Our solutions deliver speed, transparency, and accuracy never thought possible. To learn more, visit our HCC Complete page. 

1.  Apixio survey

Udorn Chanthavong Profile Image
Udorn Chanthavong